The evolution of minimally invasive valve surgery--2 year experience

The aim of the study was to evaluate the evolution of Port-Access minimally invasive mitral valve surgery to a robot assisted video assisted solo surgery approach.

One hundred and twenty-nine patients with non-ischemic mitral valve disease underwent 3D-video assisted mitral valve surgery via a 4 cm right lateral minithoracotomy using femoro-femoral bypass and endoaortic clamping. Transcranial Doppler and continuous transesophageal echocardiography were used to monitor placement and positional stability of the endoclamp. After the initial series (group I, n = 62), a simplified solo surgical technique using voice controlled robotic assistance for videoscope guidance was used in the last 67 patients (group II).

After an initial learning curve and modifications of catheter design, the procedure could be steadily redefined and simplified. In the last 67 patients, the procedure was completed without the need for an additional assistant as 'solo surgery'. The mitral valve was repaired in 72 and replaced in all other patients. Duration of bypass and clamp time steadily improved during our study and in the most recent 67 patients average 107 +/- 34 and 48 +/- 16 min, respectively. The voice controlled robotic arm (AESOP 3000, Automated Endoscope System for Optimal Positioning) provided a stable and precise video image with excellent exposure of all valvular and subvalvular structures. Hospital mortality was high in the early series (mean survival 88.7% at 804 +/- 35 days; 95% CI: 735-873) and partially procedure related (aortic dissection in two patients). In group II, hospital mortality has declined to 3.0% (mean survival 97.0% at 568 +/- 12 days; 95% CI: 553-600).

Port-Access minimally invasive mitral valve surgery has evolved to be a reliable video assisted technique with reproducible results. Surgery can now be performed almost in the same time as with conventional techniques. Robotic assistance has enabled a solo surgery approach.